Primary care clinicians should initiate treatment options for advanced chronic kidney disease with older patients, according to the authors of a new review published in JAMA Internal Medicine.
Because older adults are often ineligible for transplant, the main options for managing chronic kidney disease often are conservative care or dialysis, with the latter frequently presented as the default, write a team of nephrologists, palliative care specialists, and geriatricians.
But the effects of dialysis on quality of life may outweigh the benefits of prolonging survival for some older patients.
Primary care clinicians “have a deep understanding of their patients’ values and preferences, which can further guide shared decision-making around kidney therapy options,” said Jane O. Schell, MD, an associate professor and section chief of palliative care and medical ethics at the University of Pittsburgh, Pennsylvania, who helped write the review.
But many “feel like they don’t have the expertise to talk” about whether dialysis or conservative treatment may be better for their patient, Schell said.
The new review advises that primary care clinicians discuss options when a patient has a glomerular filtration rate below 30 mL/min/1.73m2, but they can also start shared decision-making conversations when a patient’s illness is mild.
Playing It Conservative
The multidisciplinary approach involves managing potential complications of chronic kidney disease, such as electrolyte abnormalities and anemia, and planning for end of life, advance care directives, and medical crises.
The conservative approach focuses on optimizing quality of life and involves fewer health care visits. Primary care clinicians can be essential in helping to convey this information to patients, Schell said.
Although dialysis can prolong survival, the benefit is often minimal for those over age 65. A 2024 study showed dialysis patients with a mean age of 77 years lived 9 days longer than those who opted for conservative care, which entailed symptom management and emotional support.
However, other studies have shown wider variance; a meta-analysis of 12 studies showed after making a treatment decision, those who went with conservative care died an average of 14 months earlier than those who started dialysis.
But research has shown many patients with kidney failure are started on dialysis without informed understanding of other options, and that a portion of patients who start the treatment later regret doing so.
“What stands out is how often patients and families don’t receive the full picture before starting dialysis; many assume it is the only path forward, when in reality, dialysis can mean more hospital visits, more fatigue, and less time at home,” said Annie DePasquale, MD, a family physician in Arlington, Virginia, who was not involved in the review. “For many older adults with multiple comorbidities, the focus should shift from prolonging life at any cost to maximizing comfort, autonomy, and time at home with loved ones.”
If a patient does choose dialysis after hearing the risks and benefits, primary care clinicians should discuss other logistical issues.
Most patients undergo dialysis at a treatment center, with visits lasting roughly 4 hours, three times a week. Transportation can be a significant challenge, as patients cannot drive themselves home after treatments. Some insurers may offer non-emergency medical transportation to treatment, but coverage varies. Alternatively, patients can choose home dialysis, which typically is administered over 2 to 3 hours, five times a week.
“We owe it to our patients to present all options openly, including what living with dialysis truly looks like day to day,” DePasquale said.
Abbreviated geriatric assessment tools such as the Mini-Mental State Examination can help primary care clinicians determine factors that may influence how an older individual might fare on dialysis, including frailty, functional impairment, cognitive impairment, and social support needs, Schell said.
Some patients at low risk for chronic kidney disease progression can choose not to decide, and revisit later when kidney function has declined. If patients remain ambivalent, a limited-time dialysis trial of a few weeks can help guide choices, Schell said.
“Primary care providers are often the clinicians who know patients best and we can help by starting these conversations early, long before kidney function reaches a crisis point,” DePasquale said. “Using plain language, shared decision-making tools, and family discussions, we can guide patients toward choices that reflect their goals, whether that means starting dialysis or opting for a conservative, comfort-focused approach.”